Ethical dilemmas when elective surgery is cancelled

Planned operations are sometimes cancelled when the health care system is overwhelmed by emergency cases. Hospitals lose money and efficiency decreases, and patients who have prepared have their surgery cancelled. In an article in Clinical Ethics, researchers at Uppsala University, Karolinska Institutet and Karolinska University Hospital claim that this has ethical, psychological, and medical consequences.

When the first snow falls, Swedish emergency rooms are filled with fractured hips and legs. To deal with emergency cases, hospitals often have to cancel elective surgery. In a recent article in Clinical Ethics, a group of researchers at Uppsala University, Karolinska Institutet, and Karolinska University Hospital in Huddinge has published results that suggest that having your planned operation cancelled can have serious medical and psychological consequences. 

In an explorative pilot study, the researchers have shown that cancellations of planned elective surgeries lead to medical problems for the patients whose operations are postponed. But according to Mats G. Hansson, professor of Biomedical Ethics at Uppsala University, these cancellations without medical reasons lead to an ethical dilemma.

- When resources in the health care system are scarce, we have to prioritize. Priorities based on medical needs are perceived as fair. But sometimes it seems as though there is an ‘invisible hand’ administrating these priorities, says Mats G. Hansson.

The patients who are pushed aside for the benefit of emergency patients have to handle their disappointment and anger in the face of hospital planning. The cancelled surgery means they have to revisit a difficult process of preparing for the surgery. But it also leads to longer sick leave, cancelled or re-scheduled follow up visits with short notice and costs for alternative treatments like physiotherapy or chiropractor visits.

- When surgery is cancelled for medical reasons, patients react differently. This kind of administrative cancellations can make patients feel like victims who have no control. The psychological disappointment for a patient who has prepared for surgery can cause damage too. Anger with unprofessional attitudes at the time of cancellation, inadequate information, or lack of empathy can make the situation worse, say Leif Ryd, associate professor and Li Felländer-Tsai, professor at Karolinska Institutet and chief physicians at Karolinska University Hospital.

This is the first time that consequences of postponed surgery have been analyzed in terms of medical complications and postoperative results.

- Compared to a matched set of patients, it seems like these patients who have had their operations moved fare worse, says Håkan Magnusson, MD and lead author of the article.

Facts about the study: The researchers’ hypothesis was that cancellations are followed by poorer clinical results, mainly on psychological grounds. Postponed hip or knee joint replacement surgeries were compared to a matched set that had not been postponed. The results show that cancelled operations result in significantly more complications and a lower quality of life in the long run. Some patients had been notified a few weeks in advance, but the study included some who had found out five minutes before the surgery was to be performed. The most common complications were depression, urinary tract infection, wound infection, and myocardial infarction. Myocardial infarction was the only single complication to border on statistical significance between groups.

The research group will now go on to conduct a larger prospective study.

More information:
Håkan Magnusson, MD, Södertälje Hospital (Stockholm South General Hospital), hakan.magnusson@sodertaljesjukhus.se, +46 (0)8-550 240 00
Li Felländer-Tsai, professor, chief physician, Karolinska Institutet & Karolinska University Hospital, li.tsai@ki.se, +46 (0)8-585 82102
Mats G. Hansson, professor of biomedical ethics, Centre for Research Ethics & Bioethics, Uppsala University, mats.hansson@crb.uu.se, +46 (0)763-41 20 50
Leif Ryd, associate professor, chief physician, Karolinska Institutet & Karolinska University Hospital, leif.ryd@karolinska.se, 0707-48 44 51

Magnusson, H, Felländer-Tsai, L, Hansson MG and Ryd, L, Cancellations of elective surgery may cause an inferior postoperative course: the ’Invisible hand’ of health care prioritization?, Clinical Ethics 2011;6(1):27-31.

Clinical Ethics is published by the British Royal Society of Medicine, United Kingdom.

Centre for Research Ethics & Bioethics.